Nokea
The nurse is teaching a client with a new diagnosis of epilepsy about medication adherence. Which of the following instructions is most important?
- A. Take the medication exactly as prescribed.
- B. Skip doses if you feel well.
- C. Double the dose if you miss one.
- D. Stop the medication if side effects occur.
Correct Answer: A
Rationale: Taking antiepileptic medication exactly as prescribed is critical to prevent seizures.
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A child has been prescribed diphenhydramine hydrochloride (Benadryl) to help control the itching from atopic dermatitis. The nurse should instruct the parents to report: Select all that apply.
- A. Weight loss.
- B. Drowsiness.
- C. Thickened bronchial secretions.
- D. Upset stomach.
- E. Bradycardia.
Correct Answer: B, C, D
Rationale: Diphenhydramine can cause drowsiness, thickened bronchial secretions, and upset stomach as side effects, which should be reported.
A client with type 2 diabetes is prescribed metformin. Which laboratory value should the nurse monitor?
- A. Serum creatinine.
- B. Hemoglobin A1c.
- C. Platelet count.
- D. Serum sodium.
Correct Answer: A
Rationale: Metformin can affect renal function, so monitoring serum creatinine is essential to assess kidney function.
The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which of the following in the future?
- A. Hearing problems.
- B. Speech defect.
- C. Chronic sinus infections.
- D. Tonsillitis.
Correct Answer: A, B
Rationale: Cleft palate repair increases the risk of hearing problems (due to Eustachian tube dysfunction) and speech defects.
A 30-week-gestation client admitted in preterm labor is prescribed betamethasone. What should the nurse tell the client is the purpose for this medication?
- A. Promote fetal lung maturity.
- B. Delay delivery for at least 48 hours.
- C. Stop the premature uterine contractions.
- D. Prevent premature closure of the ductus arteriosus.
Correct Answer: A
Rationale: Betamethasone, a corticosteroid, is administered to increase the surfactant level and increase fetal lung maturity, reducing the incidence of respiratory distress syndrome in the newborn infant. Surfactant production does not become stable until after 32 weeks' gestation. If adequate amounts of surfactant are not present in the lungs, respiratory distress and death are possible consequences. Delivery needs to be delayed for at least 48 hours after the administration of betamethasone in order to allow time for the lungs to mature. The remaining options are incorrect.
Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.
- A. Accepting the client while not arguing with the delusion.
- B. Focusing on the feelings or meaning of the delusion.
- C. Focusing on events and topics based in reality.
- D. Confronting the client's beliefs.
- E. Interacting with the client only when he is based in reality.
Correct Answer: A,B,C
Rationale: To manage grandiose delusions, the nurse should accept the client without reinforcing the delusion, focus on the underlying feelings, and redirect to reality-based topics. Confronting beliefs or limiting interaction to reality-based moments can escalate agitation or alienate the client.